Impact on decisions to start or continue medicines of providing information to patients about possible benefits and/or harms: a systematic review and meta-analysis

The Human Dimension: Putting the Person into Personalised Medicine

Technological advances enabling us to personalise medical interventions at the biological level must be matched by parallel advances in how we support the informed choices essential to patient and public participation. We cannot take participation for granted. To be truly personalised, medicine must take account of the perceptions and capabilities that shape participation. To do this, we need a better understanding of how people perceive personalised medicine and how they judge its value and risks. To realise the promise of 4P medicine we need to personalise at the psychosocial as well as biological dimension, putting the person into personalised medicine.

Words or numbers? Communicating risk of adverse effects in written consumer health information: a systematic review and meta-analysis

BACKGROUND

Various types of framing can influence risk perceptions, which may have an impact on treatment decisions and adherence. One way of framing is the use of verbal terms in communicating the probabilities of treatment effects. We systematically reviewed the comparative effects of words versus numbers in communicating the probability of adverse effects to consumers in written health information.

METHODS

Nine electronic databases were searched up to November 2012. Teams of two reviewers independently assessed studies.

INCLUSION CRITERIA

randomised controlled trials; verbal versus numerical presentation; context: written consumer health information.

RESULTS

Ten trials were included. Participants perceived probabilities presented in verbal terms as higher than in numeric terms: commonly used verbal descriptors systematically led to an overestimation of the absolute risk of adverse effects (Range of means: 3% - 54%). Numbers also led to an overestimation of probabilities, but the overestimation was smaller (2% - 20%). The difference in means ranged from 3.8% to 45.9%, with all but one comparison showing significant results. Use of numbers increased satisfaction with the information (MD: 0.48 [CI: 0.32 to 0.63], p < 0.00001, I2 = 0%) and likelihood of medication use (MD for very common side effects: 1.45 [CI: 0.78 to 2.11], p = 0.0001, I2 = 68%; MD for common side effects: 0.90 [CI: 0.61 to 1.19], p < 0.00001, I2 = 1%; MD for rare side effects: 0.39 [0.02 to 0.76], p = 0.04, I2 = not applicable). Outcomes were measured on a 6-point Likert scale, suggesting small to moderate effects.

CONCLUSIONS

Verbal descriptors including "common", "uncommon" and "rare" lead to an overestimation of the probability of adverse effects compared to numerical information, if used as previously suggested by the European Commission. Numbers result in more accurate estimates and increase satisfaction and likelihood of medication use. Our review suggests that providers of consumer health information should quantify treatment effects numerically. Future research should focus on the impact of personal and contextual factors, use representative samples or be conducted in real life settings, measure behavioral outcomes and address whether benefit information can be described verbally.

Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study

Background

Elderly patients with multimorbidity who are treated according to guidelines use a large number of drugs. This number of drugs increases the risk of adverse drug events (ADEs). Stopping medication may relieve these effects, and thereby improve the patient’s wellbeing. To facilitate management of polypharmacy expert-driven instruments have been developed, sofar with little effect on the patient’s quality of life. Recently, much attention has been paid to shared decision-making in general practice, mainly focusing on patient preferences. This study explores how experienced GPs feel about deprescribing medication in older patients with multimorbidity and to what extent they involve patients in these decisions.

Methods

Focusgroups of GPs were used to develop a conceptual framework for understanding and categorizing the GP’s view on the subject. Audiotapes were transcribed verbatim and studied by the first and second author. They selected independently relevant textfragments. In a next step they labeled these fragments and sorted them. From these labelled and sorted fragments central themes were extracted.

Results

GPs discern symptomatic medication and preventive medication; deprescribing the latter category is seen as more difficult by the GPs due to lack of benefit/risk information for these patients.

Factors influencing GPs’deprescribing were beliefs concerning patients (patients have no problem with polypharmacy; patients may interpret a proposal to stop preventive medication as a sign of having been given up on; and confronting the patient with a discussion of life expectancy vs quality of life is ‘not done’), guidelines for treatment (GPs feel compelled to prescribe by the present guidelines) and organization of healthcare (collaboration with prescribing medical specialists and dispensing pharmacists.

Conclusions

The GPs’ beliefs concerning elderly patients are a barrier to explore patient preferences when reviewing preventive medication. GPs would welcome decision support when dealing with several guidelines for one patient. Explicit rules for collaborating with medical specialists in this field are required. Training in shared decision making could help GPs to elicit patient preferences.

Understanding rational non-adherence to medications. A discrete choice experiment in a community sample in Australia

Background

In spite of the potential impact upon population health and expenditure, interventions promoting medication adherence have been found to be of moderate effectiveness and cost effectiveness. Understanding the relative influence of factors affecting patient medication adherence decisions and the characteristics of individuals associated with variation in adherence will lead to a better understanding of how future interventions should be designed and targeted. This study aims to explore medication-taking decisions that may underpin intentional medication non-adherence behaviour amongst a community sample and the relative importance of medication specific factors and patient background characteristics contributing to those decisions.

Methods

A discrete choice experiment conducted through a web-enabled online survey was used to estimate the relative importance of eight medication factors (immediate and long-term medication harms and benefits, cost, regimen, symptom severity, alcohol restrictions) on the preference to continue taking a medication. To reflect more closely what usually occurs in practice, non-disease specific medication and health terms were used to mimic decisions across multiple medications and conditions.161 general community participants, matching the national Australian census data (age, gender) were recruited through an online panel provider (participation rate: 10%) in 2010.

Results

Six of the eight factors (i.e. immediate and long-term medication harms and benefits, cost, and regimen) had a significant influence on medication choice. Patient background characteristics did not improve the model. Respondents with private health insurance appeared less sensitive to cost then those without private health insurance. In general, health outcomes, framed as a side-effect, were found to have a greater influence over adherence than outcomes framed as therapeutic benefits.

Conclusions

Medication-taking decisions are the subject of rational choices, influenced by the attributes of treatments and potentially amenable to intervention through education, strategic pricing and the altering of dosing characteristics. Understanding individual treatment preferences is thus an important step to improving adherence support provision in practice. Re-framing future interventions and policies to support rational and informed individual patient choices, is the way forward to realising the full potential health and economic benefits from the efficacious use of medications.